Invisalign Clear Aligner Orthodontic Therapy: Questionnaire

Invisalign Clear Aligner Orthodontic Therapy: Questionnaire
1. I am:

An adult considering invisalign A teen considering invisalign An adult considering invisalign for my child
2. Which best describes the orthodontic therapy you've had in the past?

Braces Palate expander Invisalign Orthodontics Space mantainer Headgear Retainers Never had orthodontic treatment
2a. If you have experienced Dental Braces relapse. When did you first become aware of the problem?

Less than 1 year 1-5 years 5-20 years 20+ years Never had Orthodontic therapy Never had any dental braces relapse My teeth have shifted, but I've never had orthodontic therapy Not applicable
3. Do you have all your adult teeth (except your wisdom teeth)?

Yes No Not sure
4. What do you hope to achieve from Invisalign Orthodontic Therapy?

More even bite Less crowding Healthier gums and bone Reduce overbite Straighter teeth Improve profile Make brushing easier Close gaps Improve my smile Make flossing easier Increase confidence Reduce staining and plaque buildup None of the above
5. How many times per day do you brush?

1 2 3 or more Less than 1
6. How many times per day do you floss?

0 1 2 or more
7. Which statement do you agree with?

A healthy mouth is an important part of my overall health. A beautiful smile is very important to me. My primary goal is to have straight teeth, but, general dental health is important too. My primary goal is to have excellent dental health. None of the above.
8. Do you have any orthodontic insurance coverage?

Yes No I don't know
9. Can you benefit from a health savings account (HSA) flexible spending account (FSA)?

Yes No I don't know
10. If everything works out, when would you like to start Invisalign Ortodontic Therapy?

Immediately In the next 6 months Next January As soon as I can arrange the finances Not sure yet
11. How much research have you done?

Just started Spoke with my dentist about Invisalign but have not had an evaluation Have an appointment scheduled for an evaluation Had an Invisalign consultation and would like a second opinion Ready to schedule an appointment to start Invisalign treatment
12. Have you ever been told that you were not a candidate for Invisalign?

Yes No Sort of Not sure
13. If you have had an Invisalign specific consultation, was your treatment classified as:

Basic Standard Advanced Complex I haven't had an Invisalign consultation I was told I couldn't have Invisalign Not sure
14. Would you be opposed to having your teeth whitened by an oral antiseptic agent during the therapy?

Yes No Possibly
Full Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
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